Nokea
The nurse is teaching a client how to ambulate using a walker. The nurse should
- A. Have the client stand on the side of the walker to have them properly fitted.
- B. Position the top of the walker so it lines up with the client's wrist crease.
- C. Ensure the client's feet are close together while holding onto the walker handgrips.
- D. Instruct the client to lean forward over the walker so they do not lose balance.
- G. None
Correct Answer: B
Rationale: The walker’s top aligns with the wrist crease for proper height. Standing on the side, close feet, or leaning forward are unsafe or incorrect for fitting or use.
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The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?
- A. Call for help to get the client back in bed
- B. Assist the client back to bed
- C. Establish if the client is responsive
- D. Ask the client what happened
Correct Answer: C
Rationale: Establishing responsiveness ensures the client’s immediate safety and guides further actions. Other steps follow after assessing the client’s condition.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
- A. Dull tone over the spleen
- B. Hyperresonance over an adult's lung tissue
- C. Flat tone over bone
- D. Hyperresonance over a child's lung tissue
Correct Answer: B
Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.